PreSeminarExerciseInstructions

Participation in the live seminar component of Delivering Medication Therapy

Management Services requires completion of a pre-seminar exercise.

Participants must complete two patient cases.

For the first case, participants should interview one patient with three or more
chronic conditions AND five or more medications. The documentation listed
below will need to be completed for this case (forms can be found on subsequent
pages):
Authorization for Medication Review

o The Authorization form should not be turned in.

o This is intended to cover the pharmacists involvement with the patient
from a liability standpoint as well as to inform the patient about his or her
involvement with the medication review.
Patient History Form (to be filled out by the patient as part of the information

gathering process.)
Medication Therapy Review (MTR)

The second case for participants to accomplish involves the standardized case
(patient Toni). The documentation listed below need to be completed for this case:
Medication-Related Problem Prioritization List
Personal Medication Record (PMR)
Medication-Related Action Plan (MAP)
SOAP Note

Friends, family, and/or other patients with whom the pharmacist feels comfortable are
all appropriate candidates for this activity. The pharmacist should explain to the
patient that the interview and documentation is for educational purposes only, and the
patients identity will remain confidential. To maintain patient privacy, participants
need to ensure that no patient identifying information is included on the
documentation.

Participants should bring all completed forms to the live seminar because these
will be required for admittance.

Participants should be prepared to use these patient cases during interactive portions
of the live seminar.

PreSeminarExercise
Toni
Toni is a 46-year-old African American female patient. She was diagnosed with diabetes
approximately 1 year ago and began glipizide XL 10 mg daily. The diagnosis frightened
her, so she lost 5 lb, adhered to her medication regimen, and educated herself about
diabetes. She returned to her doctor 6 months ago. Her physician said that her numbers
had improved, but she still was well outside her therapeutic range, so the physician
increased her glipizide XL to 10 mg twice daily. Toni saw your MTM brochure at the
clinic and made an appointment for a medication therapy review today (9/1/08).
Here is the pharmacys record of her medications:
Medication
HCTZ/Triamterene 25 mg/37.5 mg
Felodipine 5 mg
Simvastatin 20 mg
Simvastatin 40 mg
Glipizide XL 10 mg
Glipizide XL 10 mg
Ibuprofen 400 mg

Sig
1 daily
1 daily
1 at bedtime
1 at bedtime
1 daily
1 twice daily
As needed

#
30
30
30
30
30
60
30

Original Fill
6/28/02
11/22/04
11/3/04
1/6/08
9/10/07
3/6/08
7/16/04

Last Fill
8/10/08
8/10/08
12/1/07
8/2/08
2/6/08
8/10/08
4/21/08

She has filled out a Patient Information Form (attached). During the patient interview,
you discover the following:
SH: Very sedentary at work. Watches TV several hours each night. Snacks throughout
the day and evening while working and watching TV. She smokes about 10 cigarettes a
day. A knee replacement 2 years ago has limited her physical activity.
ROS: c/o fatigue and frequent urination. She gets up two to three times a night to go to
the bathroom. She reports no episodes of hypoglycemia.
PE:

BP 142/88 HR 78 RR 18
Weight is 250 lb. After an initial weight loss, she became frustrated and has
gained 10 lb over the past year.
Monofilament test indicates good sensation in both feet.

Laboratory Results (point-of-care testing last month):

Glucose
A1C
FBG
LFTs
AST
ALT

9%
240 mg/dL
40 Units/L
35 Units/L

Cholesterol (fasting)
TC
210 mg/dL
HDL
30 mg/dL
TRG
300 mg/dL
LDL
120 mg/dL

HIPAA Note
Patient Name: TONI xxxxxxxxxxxPatient Identifier:
Certain99-09999
information
blacked out to conceal
PATIENT INFORMATION FORM
protected health
Please complete the following information in preparation for your medication review. Shaded boxes are for
information.
pharmacist use.
Address:

Date of Birth:

231 Green Ave

Date:

9/1/11

10/31/65 Age:

46

Garland, TX

City, State, Zip:

Sex

;F

White

;Black

972-330-2525

Asian

Hispanic

Toni@gmail.com

Native American

Other______

Phone:

972-555-2525

Cell:
E-mail:

Height: 5'8"______

Race:

Weight: 250 lb______

Medication Allergies:

Reaction:

Codeine

Upset stomach_________________________

SOCIAL HISTORY
Marital Status:

Single

Exercise:

minutes

Married

Caffeine:

cups/day

Partnered

Alcohol:

14

drinks/week

Separated

Tobacco: ____1/2_____packs/day for ___10______years

;Divorced

;Current

Widowed

Past

times per week

Never

Illicit drugs: none

Occupation: Customer Service Representative

FAMILY HISTORY
;Cancer

;Diabetes

;High cholesterol

;Depression

;Heart attack

;Kidney disease

;High blood
pressure
;Stroke

Other:___________
PAST MEDICAL HISTORY
Asthma

Cancer

;High cholesterol

;Anxiety

Heart attack

COPD

Cancer

;High blood
pressure

;Diabetes

Stroke

;Depression

Irregular heartbeat
(atrial fibrillation)

;Difficulty sleeping

Ulcers
(stomach/intestine)
Thyroid disease
Other___________

GERD (acid reflux)

Page 1 of 2

Patient Name: TONI xxxxxxxxxxx Patient Identifier:

99-09999

PAST SURGICAL HISTORY

Appendectomy

Hysterectomy

Angioplasty
(balloon surgery or stent)

CABG (bypass surgery)

;Knee replacement

Hip replacement

Pacemaker/defibrillator

;Live births #_____3_______

Other:___________________

CURRENT MEDICATIONS (include all medicines: prescribed, over-the-counter, vitamins, herbal medicines)
Name and strength of your
medicine?

How do you take

it?

For how
long?

What is it for?

Doctor

HCTZ 25 mg/
Triamterene 37.5 mg

1 daily

6 years

Blood pressure

Cartman

Felodipine 5 mg

1 daily

4years

Blood pressure

Cartman

Simvastatin 40 mg

1 at bedtime

4 years

Cholesterol

Cartman

Glipizide XL 10 mg

2 times a day

1 year

Diabetes

Singh

Ibuprofen 400 mg

As needed

4 years

Pain

Lucas

Chromium

1 daily

1 year

Diabetes

Magnesium

1 daily

1 year

Diabetes

Multivitamin

1 daily

1 year

Tired

Ranitidine 75 mg

2 times a day

4 years

Stomach

Page 2 of 2

MEDICATIONRELATEDPROBLEMPRIORITIZATIONLIST
Medication-Related Problem

Details

Priority
(Low, Medium, High)

MYMEDICATIONRECORD

Name:_____________________________________________Birthdate:____________________________
Includeallofyourmedicationsonthisrecord:prescriptionmedications,nonprescriptionmedications,herbalproducts,andotherdietary
supplements.Alwayscarryyourmedicationrecordwithyouandshowittoallyourdoctors,pharmacists,andotherhealthcareproviders.

Drug
Takefor
WhendoItakeit?
StartDate
StopDate
Doctor
SpecialInstructions
Name

Dose

ThissamplePersonalMedicationRecord(PMR)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstituteprofessionalhealthcareadviceortreatment.The
patient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oractonthebasisof,thePMRortheinformationtherein.Ifheorshedoesso,thenheorshedoes
soathisorherownrisk.Whileintendedtoserveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,thePMRisnotasubstituteforobtaining
professionalhealthcareadviceortreatment.ThisPMRmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociationofChainDrugStoresFoundationand
theAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,orcompletenessofanyinformationprovidedorrecordedherein.

ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociationofChainDrugStoresFoundation.Reproducedwith
permissionfromAPhAandNACDS.


MYMEDICATIONRELATEDACTIONPLAN

Patient:
Doctor(Phone):
Pharmacy/Pharmacist(Phone):
DatePrepared:

ThelistbelowhasimportantActionStepstohelpyougetthemostfromyourmedications.
FollowthechecklisttohelpyouworkwithyourpharmacistanddoctortomanageyourmedicationsAND
makenotesofyouractionsnexttoeachitemonyourlist.

ActionstepsWhatIneedtodo

NotesWhatIdidandwhenIdidit.

MyNextAppointmentwithMyPharmacistison:______________(date)at_________ AMPM
ThissampleMedicationRelatedActionPlan(MAP)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstitute
professionalhealthcareadviceortreatment.Thepatient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oracton
thebasisof,theMAPortheinformationtherein.Ifheorshedoesso,thenheorshedoessoathisorherownrisk.Whileintendedto
serveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,theMAPisnotasubstituteforobtaining
professionalhealthcareadviceortreatment.ThisMAPmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociation
ofChainDrugStoresFoundationandtheAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,or
completenessofanyinformationprovidedorrecordedherein.

ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociation
ofChainDrugStoresFoundation.ReproducedwithpermissionfromAPhAandNACDSFoundation.

MedicationTherapyReviewSOAPNotesForm
Patient Name:
Patient ID:

Insurance Company:

Date of Birth:

Age:

Sex:

Evaluation Date:

Subjective (what the patient tells you):

Objective (information you gather from physical exam, labs):

Assessment (problems you found, from most important to least important):

Plan (what interventions will be initiated for each problem):

PatientHealthandHistoryReview

02/06/30
Avelina Espinas
Name:______________________________Date:______________DOB:______________
Sex(circleone):MF

Married
MaritalStatus:_________________________

905-387-8339
TelephoneNumber(s)Home:___________________Work:_______________________
196 Solomon Cr.
HomeAddress:______________________________________________________________
Solomon Cr.
Street:_____________________________________________________________________
Ontario
Hamilton
City:__________________________
State:____________

L8W 2G7
ZIP:_________________

Anastacio
Whoisyourprimarycarephysician?_____________________________________________
April 20, 2013
Whenwasyourlastcompletecheckup?__________________________________________

FamilyHistory(mother,father,brother,sister,grandparents)

x Highcholesterol
x Highbloodpressure
Diabetes
x Stroke
x Heartattack
Kidneydisease
Depression
Cancer
Other:__________________

PastMedicalHistory

PastSurgicalHistory

x
Asthma
Highbloodpressure
Appendectomy
Irregularheartbeat(atrial
Heartattack
Angioplasty(balloon
fibrillation)
surgery)orstent
Anxiety
Insomnia(difficulty
CABG(bypasssurgery)
sleeping)
Hipreplacement
COPD
GERD(acidreflux)
Hysterectomy
Diabetes
Ulcers(stomach/intestine)
Kneereplacement
Depression
Thyroiddisease
Pacemaker/defibrillator
x Highcholesterol
x Livebirths#__________
Stroke
5
Cancer
Other:_______________
Other:__________________
Osteoporosis

Allergies(includemedicationandfood):__________________________________________
n/a
___________________________________________________________________________

Intolerances(includesideeffectsfrompreviousmedications,suchasnausea,constipation,
constpation, stomach aches
sleepiness,dizziness,stomachupset,etc.):________________________________________
______________________________________________________________________________
________________________________________________________________________

Adapted from: Joseph Ineck, PharmD

Creighton University Medical Center


CurrentSymptomReview:
Ifyouareexperiencinganysymptomsfromthefollowinglist,circleallthatapply.
Ifnosymptoms,checknone.

Constitutional:
Weightloss
Nightsweats
()None
x Weightgain
Fatigue

HEENT:
Visionproblems
Doublevision
()None
x
Glaucoma
Cataracts

x
Hearingproblems
Ringingintheears
()None
Earaches
Sensationofroomspinning
Other:______________________

Nasalcongestion
Nasaldischarge
()None
x
Nosebleeds
Infection

Other:______________________

x Problemsswallowing
Hoarsevoice
()None
Soremouthorthroat
Bleedinggums

Other:______________________
Endocrine:
Swollenglands
Thyroidproblems
()None
x
Diabetes

Other:______________________
Respiratory:
Cough
Shortnessofbreath
()None
x
Sputum
Wheezing

Cigarettesmoking

Other:______________________
Cardiac:
x Highbloodpressure
Heartpain
()None
Heartirregularity
Palpitations

x
Swellinginthelegs
Difficultybreathingwhenlyingflat
"shakey"
Other:______________________
Gastrointestinal:
x Constipation
Reflux
()None
Heartburn
Stomachorintestinalulcer
Hepatitis
Nauseaand/orvomiting
xOther:______________________
diarhhea
Genitourinary:
x
Frequency
Burningwithurination
()None
Bloodinurine
Difficultyholdingorcontrollingurine
Other:______________________
Musculoskeletal:
x
Jointaches
Muscleweakness
()None
Adapted from: Joseph Ineck, PharmD
Creighton University Medical Center

Legweakness
Musclecramps

Other:______________________
Neurology:
x
Headache
Migraine
()None
Seizure
Numbness

Tremors
Fainting

Other:______________________
Heme/Lymph:
Bleeding
Bloodclots
()None
x
Swollenglands

Other:______________________
Immuno:
Allergies
Rash
()None
x
Infections

Other:______________________
Psych:
x
Depression
Cryingspells
()None
Anxiety
Sleeping

Sleepdisturbance

Other:______________________

SocialSituation:

Immediate family
Withwhomdoyoulive?_______________________________________________________

Areyoucurrentlyemployed?(circleone):
YES x NO
n/a
Nameofemployer:____________________
n/a
Position:_____________________________

Doyoupresentlysmokecigarettesorusetobaccoinanyform?(circleone):
YES xNO

Ifyes,howmanypacksdoyousmokeaday?__________

Didyoueversmokecigarettesorusetobaccoinanyform?(circleone): YES x NO

Ifyes,howmanypacksdidyousmokeaday?__________

Forhowmanyyears?________ Whendidyouquit?_________

Doyoudrinkalcoholicbeverages?(circleone): YES x NO

Ifyes,whatisyourusualconsumption(numberofdrinks)_____
ina(circleone):DAYWEEKMONTH

Didyoueverdrinkalcoholicbeverages?(circleone):
YES x NO

Ifyes,whatwasyourusualconsumption(numberofdrinks)_____
ina(circleone):DAYWEEKMONTH

Forhowmanyyears?________ Whendidyouquit?_________

Howmuchphysicalactivitydoyouperformperweek?
1h a week; walking around neigbourhood
_______________________________________________________________________
Adapted from: Joseph Ineck, PharmD
Creighton University Medical Center

Immunizations
Whendidyoulastreceivethefollowingimmunizations?
Influenza

___________
Tetanus/diphtheria/pertussis ___________
n/a
Herpeszoster

___________
Pneumoccal

___________

Other
Whatquestionsdoyouhaveaboutyourmedications?

none
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Whatconcernsdoyouhaveaboutyourhealthandmedicalconditions?

scared of heart attack or stroke.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Whatdoyouhopetogetoutofyourvisit?

security, more information, awareness of coditions and what I'm on; interactions
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Adapted from: Joseph Ineck, PharmD

Creighton University Medical Center

MYMEDICATIONRECORD

Name:_____________________________________________Birthdate:____________________________
Includeallofyourmedicationsonthisrecord:prescriptionmedications,nonprescriptionmedications,herbalproducts,andotherdietary
supplements.Alwayscarryyourmedicationrecordwithyouandshowittoallyourdoctors,pharmacists,andotherhealthcareproviders.

Drug
Takefor
WhendoItakeit?
StartDate
StopDate
Doctor
SpecialInstructions
Name
Dose

blood pressure
40 mg
Telmasartan
Crestor
20 mg heart

constipation
docusate sodium

81 mg heart
Aspirin

Actonel
150 mg bone

Vitamin B12

need it
1000 mcg

Anastacio
"
"

1 PO daily
1 PO QD
1 QD

"

1 Q day

"

1 Q week

"

1 PO daily

ThissamplePersonalMedicationRecord(PMR)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstituteprofessionalhealthcareadviceortreatment.The
patient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oractonthebasisof,thePMRortheinformationtherein.Ifheorshedoesso,thenheorshedoes
soathisorherownrisk.Whileintendedtoserveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,thePMRisnotasubstituteforobtaining
professionalhealthcareadviceortreatment.ThisPMRmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociationofChainDrugStoresFoundationand
theAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,orcompletenessofanyinformationprovidedorrecordedherein.

ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociationofChainDrugStoresFoundation.Reproducedwith
permissionfromAPhAandNACDS.

MEDICATIONRELATEDPROBLEMPRIORITIZATIONLIST
Medication-Related Problem

Details

Priority
(Low, Medium, High)


MYMEDICATIONRELATEDACTIONPLAN

Patient:
Doctor(Phone):
Pharmacy/Pharmacist(Phone):
DatePrepared:

905-578-5776
905-574-5333

ThelistbelowhasimportantActionStepstohelpyougetthemostfromyourmedications.
FollowthechecklisttohelpyouworkwithyourpharmacistanddoctortomanageyourmedicationsAND
makenotesofyouractionsnexttoeachitemonyourlist.

ActionstepsWhatIneedtodo

NotesWhatIdidandwhenIdidit.

MyNextAppointmentwithMyPharmacistison:______________(date)at_________ AMPM
ThissampleMedicationRelatedActionPlan(MAP)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstitute
professionalhealthcareadviceortreatment.Thepatient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oracton
thebasisof,theMAPortheinformationtherein.Ifheorshedoesso,thenheorshedoessoathisorherownrisk.Whileintendedto
serveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,theMAPisnotasubstituteforobtaining
professionalhealthcareadviceortreatment.ThisMAPmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociation
ofChainDrugStoresFoundationandtheAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,or
completenessofanyinformationprovidedorrecordedherein.

ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociation
ofChainDrugStoresFoundation.ReproducedwithpermissionfromAPhAandNACDSFoundation.

MedicationTherapyReviewSOAPNotesForm
Patient Name: Avelina Espinas
Patient ID:

Insurance Company:

Date of Birth: 02/06/30

Age: 83

Sex: F

Evaluation Date: 01/03/2014

Subjective (what the patient tells you):

can't swollow food; need to suck on food
feels she's gained weight
feels "shakey" when blood pressure high

Objective (information you gather from physical exam, labs):

bp: 136/85

Assessment (problems you found, from most important to least important):

Plan (what interventions will be initiated for each problem):